NCHS Data Brief ■ No. 104 ■ August 2012

Oral Health Disparities as Determined by

Selected Healthy People 2020 Oral Health Objectives for

the United States, 2009–2010

Bruce A. Dye, D.D.S., M.P.H.; Xianfen Li, M.S.; and Gina Thornton-Evans, D.D.S., M.P.H.

The Healthy People 2020 initiative contains over 1,200 objectives that serve 

as a roadmap for tracking the nation’s health (1). Oral health is 1 of 42 Healthy 

People topic areas comprising 33 objectives ranging from dental caries and 

periodontal disease, to access to preventive dental services and program 

infrastructure. One important activity of Healthy People is to monitor health 

disparities. Influential sociodemographic indicators for oral health disparities 

in the United States include poverty status and race and ethnicity (2). This 

report focuses on key Healthy People objectives covering select age groups by 

race and ethnicity and poverty status from 2009 to 2010.

Keywords: dental caries • dental sealants • edentulism • National Health and 

Nutrition Examination Survey

Untreated dental caries varied by race and ethnicity and 

poverty level among children and adolescents.

Key findings

Data from the National 

Health and Nutrition 

Examination Survey, 

2009–2010

• Approximately one in four 

children aged 3–5 and 6–9 

years living in poverty had 

untreated dental caries.

• Dental sealants were more 

prevalent among non-Hispanic 

white adolescents (56%) 

compared with non-Hispanic 

black adolescents (32%) aged 

13–15.

• Among adults aged 45–64, 

29% had a full set of permanent 

teeth (excluding third molars); 

this includes 19% of Hispanic 

adults and 11% of non-Hispanic 

black adults compared with 

nearly 35% of non-Hispanic 

white adults.

• More than one-third of older 

adults aged 65–74 living below 

the federal poverty level (34%) 

were edentulous, whereas 

approximately one-eighth 

of older adults living above 

the poverty level (13%) were 

edentulous.

14.4

11.3 2

19.3

19.8 2

25.1

10.5

17.0

13.9

18.6 2

25.8 2

24.2

14.9

11.4

9.4 2

24.6

11.7

20.2

9.4

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

0 5 10 15 20 25 30

13–15 years

6–9 years

Ages 3–5 years

Percent

Figure 1. Prevalence of untreated dental caries among children and adolescents, by age, race 

and ethnicity, and poverty level: United States, 2009–2010.

1

Reference group.

2

p < 0.05.

SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2009–2010.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics
NCHS Data Brief ■ No. 104 ■ August 2012

■  2  ■

In 2009–2010, 14% of children aged 3–5 years had untreated dental caries (Figure 1). Among 

children aged 6–9 years, 17% had untreated dental caries, and among adolescents aged 13–15, 

11% had untreated dental caries. Among children aged 3–5 years, the prevalence of untreated 

caries was significantly higher for non-Hispanic black children (19%) compared with nonHispanic white children (11%). Untreated caries was nearly twice as high for Hispanic children 

(26%) compared with non-Hispanic white children (14%) aged 6–9 years, and was more than 

twice as high for non-Hispanic black adolescents (25%) compared with non-Hispanic white 

adolescents (9%) aged 13–15. For children aged 3–5 and 6–9 years living at or below 100% of 

the federal poverty level, untreated dental caries was significantly higher compared with children 

living above the poverty level. For adolescents, the difference in the prevalence of untreated 

caries was not statistically significant between the two income groups. 

Prevalence of dental sealants varied by poverty status among children, and 

varied by race and ethnicity among adolescents.

Thirty-two percent of children aged 6–9 years and 51% of adolescents aged 13–15 had at least 

one dental sealant on a permanent tooth in 2009–2010 (Figure 2). Dental sealant prevalence was 

lower among children living at or below 100% of the federal poverty level (26%) compared with 

children living above the poverty level (34%). A similar pattern was found among adolescents 

aged 13–15, but the difference was not statistically significant. Dental sealant prevalence was 

significantly lower for non-Hispanic black adolescents (32%) compared with non-Hispanic white 

adolescents (56%), among those aged 13–15.

0 10 20 30 40 50 60

13–15 years

Ages 6–9 years

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

Percent

32.1

35.5

27.3

26.8

2

25.5

34.3

50.5

56.0

2

32.2

45.7

40.1

53.1

Figure 2. Prevalence of dental sealants among children and adolescents, by age, race and ethnicity, and poverty level: 

United States, 2009–2010.

1

Reference group.

2

p < 0.05.

SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2009–2010.
NCHS Data Brief ■ No. 104 ■ August 2012

■  3  ■

Tooth retention varied by race and ethnicity and poverty level among adults 

aged 25–64.

Fifty-three percent of adults aged 25–44 and 29% of adults aged 45–64 had a full set of 

permanent teeth (excluding third molars) (Figure 3). Among adults aged 25–44, tooth retention 

was lower for Hispanic (46%) and non-Hispanic black (43%) adults, compared with non-Hispanic 

white adults (58%). For adults living at 100% of the federal poverty level or lower, 42% had not 

lost a permanent tooth, whereas for adults living above the poverty level, approximately 55% had 

retained all of their permanent teeth. Complete tooth retention was more prevalent among nonHispanic white adults (35%) aged 45–64 compared with non-Hispanic black (11%) and Hispanic 

adults (19%). Complete tooth retention was also higher for adults aged 45–64 living above the 

poverty level (32%) compared with those living at or below the poverty level (15%).

0 10 20 30 40 50 60

45–64 years

Ages 25–44 years

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

Percent

52.9

58.0

2

42.5

2

45.6

2

42.0

55.4

29.3

34.5

2

10.9

2

19.4

2

15.2

31.6

Figure 3. Prevalence of complete tooth retention among adults, by age, race and ethnicity, and poverty level: 

United States, 2009–2010.

1

Reference group.

2

p < 0.05.

SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2009–2010.
NCHS Data Brief ■ No. 104 ■ August 2012

■  4  ■

Edentulism was more prevalent among adults aged 65–74 living at or below 

the federal poverty level, compared with those living above the poverty 

level.

Fifteen percent of adults aged 65–74 and 22% of adults aged 75 and over were edentulous in 

2009–2010 (Figure 4). The prevalence of complete tooth loss was more than twice as high for 

adults aged 65–74 living at or below 100% of the federal poverty level (34%), compared with 

those living above the poverty level (13%). For adults aged 75 and over, there was no significant 

difference in the prevalence of edentulism by poverty status (24% for those living at or below 

100% of the poverty level, and 21% for those living above the poverty level). Differences 

observed by race and ethnicity status among adults aged 65–74 and among those aged 75 and 

over also were not statistically significant. 

0 10 20 30 40 50 60

75 years or over

Ages 65–74 years

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

Total

Non-Hispanic white1

Non-Hispanic black

Hispanic

Below 100% of federal poverty level

Above 100% of federal poverty level1

Percent

15.0

15.2

21.6

10.7

2

34.3

13.1

21.9

20.7

24.6

28.0

23.5

20.9

1

Reference group.

2

p < 0.05.

SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2009–2010.

Figure 4. Prevalence of edentulism among older adults, by age, race and ethnicity, and poverty level: United States,

2009–2010.
NCHS Data Brief ■ No. 104 ■ August 2012

■  5  ■

Summary

More than a decade ago, the Surgeon General’s report on oral health spoke to the importance of 

engaging in activities aimed at identifying, monitoring, and reducing oral health disparities (2). 

Prior reports have shown that key social determinants affecting oral health are race and ethnicity 

and lower levels of income (1–4). Some of these reports use Healthy People objectives to describe 

the presence of oral health disparities within the U.S. population (3,4). Within the framework 

of Healthy People, oral health has evolved to include six objectives that monitor children and 

adolescents, seven objectives that monitor adults, eight objectives that focus on improving access 

to preventive dental services, seven objectives that monitor the use of interventions, and five 

objectives that relate to surveillance systems and program infrastructure (1). Finally, oral health’s 

overall importance to health is exemplified by the subject’s recognition as one of the top 12 

leading health indicators for Healthy People 2020. 

Findings from this report indicate that racial and ethnic disparities were prevalent for a variety of 

oral health indicators across various age groups. For children and adolescents, the prevalence of 

untreated dental caries varied significantly by race and ethnicity. The prevalence of dental sealants 

was significantly lower for non-Hispanic black adolescents compared with non-Hispanic white 

adolescents aged 13–15. Among adults aged 45–64, tooth retention was lower for Hispanic and 

non-Hispanic black adults compared with non-Hispanic white adults. 

Disparities based on poverty status also existed for many oral health indicators. Among children 

aged 3–5 and 6–9 years, untreated caries was significantly higher for those living at or below 

the federal poverty level compared with those living above the poverty threshold. Conversely, 

dental sealants were more prevalent among children aged 6–9 years living above the poverty level 

compared with children living in lower-income families. Prevalence of complete tooth retention 

was significantly higher among adults aged 45–64 living above the poverty level compared with 

those living in poverty. Complete tooth loss was significantly higher among adults aged 65–74 

living at or below the poverty level compared with those with higher incomes.

Definitions

Untreated dental caries: Dental cavities that have not received appropriate treatment.

Dental sealants: Plastic-like coatings that are applied to the chewing surfaces of back teeth. The 

applied sealant resin bonds into the grooves of teeth to form a protective physical barrier.

Tooth retention: Having all natural permanent teeth present, excluding third molars.

Edentulism: Having all natural permanent teeth missing, including third molars.

Poverty status or percentage of federal poverty level: An index based on the ratio of family 

income to poverty. The Department of Health and Human Services’ poverty guidelines were used 

as the poverty measure to calculate this index. Additional information can be found at http://aspe.

hhs.gov/poverty/11poverty.shtml. 
NCHS Data Brief ■ No. 104 ■ August 2012

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Data source and methods

Data from the National Health and Nutrition Examination Survey (NHANES) were used to 

produce this report. NHANES is a cross-sectional survey designed to monitor the health and 

nutritional status of the civilian noninstitutionalized U.S. population. The survey consists of 

interviews conducted in participants’ homes and standardized physical examinations in mobile 

examination centers. The sample design includes oversampling to obtain reliable estimates of 

health and nutritional measures for population subgroups. In 2009–2010, oversampling included 

non-Hispanic black and Hispanic persons aged 60 and over and low-income white persons. 

Additional information can be found on the NHANES website at http://www.cdc.gov/nchs/

nhanes.htm.

From 2009 to 2010, the NHANES oral health assessment was conducted in mobile examination 

centers by trained dental hygienists. The assessment included a tooth count to identify the 

presence or absence of permanent or primary teeth, including retained dental root tips and dental 

implants. The oral health screening also included a person-based assessment for dental caries, 

restorations, and sealants on study participants aged 3–19 years. This evaluation was a fast and 

simple process by which an examiner visually inspected the oral cavity to detect the presence or 

absence of specific oral conditions. Overall, the data reliability analyses conducted for 2009–2010 

indicated that examiner performance was similar to prior survey periods since the NHANES 

continuous survey began in 1999. Additional information regarding 2009–2010 oral health 

screening and quality assurance issues are published elsewhere (5).

The age groups used in this report approximate the age groups used for the Healthy People 

2020 oral health objectives. Key age groups include 3–5, 6–9, and 13–15 years for children and 

adolescents, and ages 45–64 and 65–74 for adults. Moreover, the Healthy People 2020 objective 

focusing on tooth retention is presented differently in this report because 2009–2010 NHANES 

data did not provide a determination of reasons for tooth loss. Consequently, the prevalence of 

complete tooth retention is shown, not the original objective highlighting no tooth loss due to 

dental disease. Additional information pertaining to Healthy People 2020 is available at http://

www.healthypeople.gov.

Population estimates and standard errors were calculated in SAS-callable SUDAAN software 

(release 10.0; RTI International, Research Triangle Park, N.C.) Sample weights to account 

for differing probabilities of selection, nonresponse, and noncoverage were used for analysis. 

The standard errors of the percentages were estimated using Taylor series linearization, to 

take into account the complex sampling design. Differences between groups were evaluated 

using a t statistic at the p < 0.05 significance level. Tests of trends were done using the p < 0.05 

significance level. All results presented in the figures have a relative standard error less than 

30%. All differences discussed are statistically significant unless otherwise indicated. Calculated 

estimates were not age adjusted, and no adjustments were made for multiple comparisons.
NCHS Data Brief ■ No. 104 ■ August 2012

■  7  ■

About the authors

Bruce A. Dye is with the Centers for Disease Control and Prevention’s (CDC) National Center for 

Health Statistics (NCHS), Division of Health and Nutrition Examination Surveys. Xianfen Li is 

with the Harris Corporation under a contract with NCHS. Gina Thornton-Evans is with the CDC’s 

National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health. 

References

1. U.S. Department of Health and Human Services. Healthy People 2020 [online]. 2010. 

Available from: http://www.healthypeople.gov [accessed 2012 Jun 1].

2. U.S. Department of Health and Human Services (HHS). Oral Health in America: A report 

of the Surgeon General. Rockville, MD: HHS, National Institute of Dental and Craniofacial 

Research, National Institutes of Health. 2000. Available from: http://silk.nih.gov/public/

hck1ocv.@www.surgeon.fullrpt.pdf.

3. Dye BA, Tan S, Smith V, et al. Trends in oral health status—United States, 1988–1994 and 

1999–2004. Vital Health Stat 11(248). 2007. Available from: http://www.cdc.gov/nchs/data/series/

sr_11/sr11_248.pdf.

4. Dye BA, Thornton-Evans G. Trends in oral health by poverty status as measured by Healthy 

People 2010 objectives. Public Health Rep 125(6):817–30. 2010.

5. Dye BA, Li X, Lewis BG, Iafolla T, Beltran-Aguilar ED, Eke P. Overview and quality 

assurance for the oral health component of the National Health and Nutrition Examination Survey 

(NHANES), 2009–2010 [forthcoming]. 2012.
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Suggested citation

Dye BA, Li X, Thornton-Evans G. Oral 

health disparities as determined by selected 

Healthy People 2020 oral health objectives 

for the United States, 2009–2010. NCHS 

data brief, no 104. Hyattsville, MD: National 

Center for Health Statistics. 2012.

Copyright information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

National Center for Health 

Statistics

Edward J. Sondik, Ph.D., Director

Jennifer H. Madans, Ph.D., Associate 

Director for Science

Division of Health and Nutrition 

Examination Surveys

Clifford L. Johnson, M.S.P.H., Director